Provider Demographics
NPI:1720383631
Name:REIDENBACH, KATHRYN ANN
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:ANN
Last Name:REIDENBACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:ANN
Other - Last Name:LANNON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:N2090 SCHINDLER RD
Mailing Address - Street 2:
Mailing Address - City:JUDA
Mailing Address - State:WI
Mailing Address - Zip Code:53550-9775
Mailing Address - Country:US
Mailing Address - Phone:608-325-4458
Mailing Address - Fax:
Practice Address - Street 1:N2090 SCHINDLER RD
Practice Address - Street 2:
Practice Address - City:JUDA
Practice Address - State:WI
Practice Address - Zip Code:53550-9775
Practice Address - Country:US
Practice Address - Phone:608-325-4458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI124189-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38285800Medicaid